Dermatological Medicines: Classes, Uses, Safety and Nursing Care

Dermatological medicines are topical, intralesional or systemic agents used to prevent, diagnose and treat disorders of the skin, hair, nails and mucous membranes. Their success depends on five linked decisions: the correct diagnosis, active medicine, strength, vehicle and duration. A medicine that is appropriate for a dry plaque on the trunk may be harmful on the eyelid, infected skin, a large body surface or an infant.

The skin is not merely a covering. It controls fluid and heat loss, provides immune and mechanical protection, permits sensation and contributes to vitamin D synthesis. Disease and topical medicines can alter all these functions. Nurses therefore assess the whole patient, not only the visible lesion.

Emergency principle: Skin pain, blistering, mucosal erosion, rapid detachment, widespread redness, fever, hypotension, breathing difficulty, facial swelling or rapidly advancing soft-tissue infection may indicate life-threatening disease. Stop suspected culprit medicines where authorised, stabilise airway/breathing/circulation and escalate urgently.

Learning Objectives

Explain factors that affect percutaneous absorption and selection of topical vehicles.
Classify dermatological medicines and explain their mechanisms, indications, adverse effects, contraindications and monitoring.
Use topical corticosteroids, emollients, antimicrobial, antiparasitic and acne medicines safely.
Calculate and teach practical application quantities using fingertip units where appropriate.
Recognise severe cutaneous adverse reactions and dermatological emergencies.
Plan individualised nursing care, patient education, follow-up and prevention.

Principles of Topical Pharmacology

Factors Affecting Skin Absorption

Body site: Eyelids, face, genital skin and flexures absorb more than thick skin on palms and soles. Potency must be reduced on thin or occluded sites.
Age: Infants have a larger surface-area-to-body-mass ratio and can absorb proportionally more medicine. Older skin is thinner and more fragile.
Skin integrity: Inflamed, eroded or diseased skin permits greater penetration than intact skin.
Hydration and occlusion: Moisture and airtight dressings increase penetration, sometimes many-fold. Occlusion should be prescribed, not improvised.
Area and duration: Applying potent medicine over a large area or for a long period increases local and systemic toxicity.
Vehicle: Ointments are more occlusive; creams are less greasy; lotions/solutions spread over hairy or large areas; gels dry quickly but may sting.

Choosing a Vehicle

Vehicle	Suitable Uses	Limitations
Ointment	Dry, thick, scaly or lichenified lesions; strong moisturising/occlusive effect.	Greasy, heat-retaining and unsuitable for many weeping lesions or very hairy sites.
Cream	Moist, flexural or cosmetically sensitive areas; easier daytime use.	Contains water and preservatives; may sting or cause contact allergy and is less occlusive.
Lotion/solution	Scalp, hairy skin, large areas or wet lesions.	Alcohol-based products may sting and dry inflamed skin.
Gel/foam	Oily or hairy sites and acne.	May irritate, dry the skin or be flammable depending on formulation.
Paste	Local protection and absorption of exudate.	Thick and difficult to spread/remove.

Fingertip Units and Quantity

One adult fingertip unit (FTU) is the amount expressed from a standard 5-mm nozzle along the fingertip from the distal crease to the tip. It is approximately enough for two adult hand-sized areas. FTU charts differ by age and body site. The nurse should demonstrate the amount rather than merely saying “apply thinly,” which often causes under-treatment or excessive use.

Emollients, Moisturisers and Barrier Preparations

Examples: Petrolatum, emulsifying ointment, paraffin-containing products, glycerol, urea-containing moisturisers and zinc oxide barriers.

Mechanism: Occlusives reduce transepidermal water loss; humectants attract water into the stratum corneum; lipid-containing products fill cracks and restore flexibility.
Indications: Atopic eczema, xerosis, ichthyosis, irritant dermatitis, fragile skin and prevention of moisture-associated skin damage.
Use: Apply generously and repeatedly, including when inflammation has improved. Smooth in the direction of hair growth rather than vigorous rubbing. Use soap substitutes where prescribed.
Adverse effects: Folliculitis, slipping hazards, contact sensitivity, stinging from urea on fissured skin and occlusion-related heat rash.
Fire hazard: Paraffin or oil residue on clothing, bedding and dressings can ignite and burn rapidly. Keep away from cigarettes, flames and heaters; washing reduces but may not remove residue.
Infection prevention: Use a pump dispenser or clean spatula rather than repeatedly putting fingers into a communal jar.

Topical Corticosteroids

Examples by increasing potency: Hydrocortisone (mild); clobetasone butyrate or similar moderate agents; betamethasone valerate (potent depending on strength/formulation); clobetasol propionate (very potent). Potency classification varies by country and product.

Mechanism: Bind intracellular glucocorticoid receptors and reduce inflammatory cytokines, vasodilation, oedema, immune-cell activity and itch.
Indications: Eczema/dermatitis, selected inflammatory dermatoses and psoriasis according to site and specialist plan. They do not cure infection.
Selection: Match potency to diagnosis, severity, site and age. Face, eyelids, flexures, genital skin and infants generally require mild preparations and short courses; thick plaques on palms/soles may need stronger treatment under supervision.
Local adverse effects: Skin atrophy, striae, telangiectasia, easy bruising, hypopigmentation, acneiform eruption, periorificial dermatitis, rosacea worsening, delayed healing and infection masking.
Systemic adverse effects: Hypothalamic–pituitary–adrenal suppression, Cushingoid effects, hyperglycaemia, growth effects and ocular complications are more likely with very potent agents, large areas, prolonged use, occlusion or young age.
Safe practice: Use the least potent effective preparation for the planned duration, continue emollients and review non-response. Do not abruptly stop prolonged extensive potent therapy without a taper/review plan.
Dangerous misuse: Steroid–antibiotic–antifungal “triple creams” can temporarily suppress redness while worsening tinea, causing tinea incognito, atrophy and antimicrobial resistance.

Topical Calcineurin Inhibitors

Tacrolimus ointment and pimecrolimus cream inhibit calcineurin-dependent T-cell activation. They are steroid-sparing options for selected atopic eczema, particularly sensitive sites, under guideline criteria. Transient burning is common. Counsel on sun protection and specialist review; they are not treatments for active bacterial, viral or fungal infection.

Dermatological Anti-infective Medicines

Topical Antibacterials and Antiseptics

Examples: Mupirocin or fusidic acid where locally recommended; chlorhexidine, povidone-iodine and other approved antiseptics.
Mechanism: Antibiotics inhibit specific bacterial targets; antiseptics act more broadly on microorganisms.
Indications: Limited impetigo, selected infected wounds or decolonisation protocols. Widespread cellulitis, fever, lymphangitis or systemic illness requires systemic assessment.
Risks: Contact dermatitis, delayed healing from harsh antiseptics, altered flora and resistance from prolonged/repeated topical antibiotics.
Stewardship: Do not automatically prescribe antibiotics for every weeping eczema flare. Optimise emollients and anti-inflammatory treatment; culture recurrent or unresponsive infection when indicated.

Topical Antifungals

Class/Examples	Mechanism and Uses	Nursing Points
Azoles Clotrimazole, miconazole, ketoconazole	Inhibit ergosterol synthesis; used for dermatophytes, candidiasis and selected Malassezia disease.	Apply beyond the visible margin and for the prescribed duration. Miconazole can interact with warfarin even when topical in some situations.
Allylamines Terbinafine	Inhibits squalene epoxidase; strong activity against dermatophytes.	Often requires a shorter topical course than azoles; not every Candida infection responds equally.
Other agents Nystatin	Binds fungal membrane sterols; active against Candida but not dermatophytes.	Do not use nystatin for ordinary ringworm/tinea.

Systemic antifungals such as terbinafine, fluconazole, itraconazole or griseofulvin are used for selected extensive disease, scalp/hair infection or onychomycosis. Confirm diagnosis where possible; review pregnancy, liver disease, cardiac disease and interactions. Monitor liver function when indicated. Tinea capitis generally requires systemic treatment because topical agents do not penetrate the infected hair shaft sufficiently.

Antiviral Medicines

Topical or systemic aciclovir/related agents inhibit viral DNA replication in herpes simplex or varicella-zoster disease. Systemic therapy is more important for extensive herpes zoster, immunosuppression, eczema herpeticum or ocular involvement. Begin early when indicated and adjust systemic doses in renal impairment. Painful clustered vesicles with fever in a patient with eczema may be eczema herpeticum and require urgent care.

Antiparasitic Medicines

Scabies

Scabies is caused by Sarcoptes scabiei. Medicine failure commonly results from incomplete application, untreated contacts, failure to repeat treatment, reinfestation or misdiagnosis—not necessarily drug resistance.

Medicine	Use and Mechanism	Precautions
Permethrin 5% cream	Disrupts parasite sodium channels. Apply to all required skin according to age/product instructions and repeat at the recommended interval.	Avoid eyes/mucosa. Follow infant and pregnancy guidance. Burning/itch may occur.
Benzyl benzoate 10–25%	Topical scabicide widely used where available; concentration/application schedule depends on age and national protocol.	Can be very irritant, especially on excoriated skin and in children; correct dilution/product is essential.
Precipitated sulfur 5–10%	Alternative topical scabicide in selected groups.	Messy, odorous and requires repeated application, but may be useful when alternatives are unsuitable.
Oral ivermectin	Binds parasite chloride channels. Used for selected ordinary, crusted or outbreak-associated scabies; often repeated because it does not reliably kill eggs.	Avoid or use specialist guidance in pregnancy and small children according to national protocol; calculate by weight and review interactions.

Complete Scabies Nursing Plan

Confirm the pattern: Nocturnal itch, burrows and typical distribution; examine contacts. Consider crusted scabies in immunosuppressed patients.
Prepare the patient: Trim nails, bathe if instructed and dry/cool the skin before topical treatment.
Cover all required sites: Apply to the whole prescribed surface, including finger/toe webs, under nails, wrists, axillae, groin, buttocks and soles; scalp/face instructions vary with age and product.
Treat contacts together: Household and close physical contacts require simultaneous management even if asymptomatic, according to guidance.
Manage textiles: Wash and hot-dry or iron recently used clothes/linen where feasible; seal non-washable items away from skin contact as directed.
Repeat correctly: Repeat after the product-specific interval to kill newly hatched mites.
Explain post-scabetic itch: Itch can persist for weeks after eradication. New burrows or new typical lesions suggest failure/reinfestation and require reassessment.

Pediculosis (Lice)

Permethrin or other locally approved pediculicides may be used with wet-combing and environmental measures. Apply exactly as labelled, repeat when required to address newly hatched lice, examine close contacts and avoid toxic insecticides or flammable home remedies. Resistance patterns and approved products vary.

Medicines for Acne

Medicine/Class	Mechanism and Role	Adverse Effects and Teaching
Benzoyl peroxide	Oxidising antibacterial and mildly comedolytic; reduces Cutibacterium acnes without bacterial resistance and helps protect antibiotic stewardship.	Dryness, irritation and bleaching of hair/fabric. Start gradually; use moisturiser and sun protection.
Topical retinoids Adapalene, tretinoin	Normalise follicular keratinisation, prevent comedones and reduce inflammation.	Irritation and photosensitivity; introduce gradually. Avoid in pregnancy according to product/guideline.
Azelaic acid	Comedolytic, antimicrobial and anti-inflammatory; may help post-inflammatory pigmentation.	Stinging and irritation; benefit develops over weeks.
Topical antibiotics Clindamycin	Reduce acne bacteria and inflammation.	Do not use as monotherapy; combine with benzoyl peroxide/other non-antibiotic therapy to reduce resistance and limit duration.
Oral tetracyclines Doxycycline or locally recommended alternative	Antibacterial and anti-inflammatory treatment for moderate–severe inflammatory acne combined with topical therapy.	Photosensitivity, gastrointestinal/oesophageal irritation; pregnancy and age restrictions. Take with adequate water and avoid unnecessary prolonged courses.
Hormonal therapy	Selected combined oral contraceptives or anti-androgen strategies reduce androgen-driven sebum.	Requires individual assessment for thrombotic and other contraindications; not suitable for every patient.
Oral isotretinoin	Strongly reduces sebum, follicular blockage and inflammation; reserved for severe/scarring or refractory acne under specialist supervision.	Highly teratogenic. Requires strict pregnancy-prevention procedures, mental-health/sexual-function review per current safety guidance, laboratory monitoring as indicated, and counselling about dryness, sun sensitivity and no blood donation.

Assess acne severity, scarring, pigmentation and psychological effects. Visible improvement commonly takes 6–8 weeks or longer. Avoid picking lesions. Refer nodulocystic acne, scarring, diagnostic uncertainty, severe distress or treatment failure.

Other Important Dermatological Medicines

Keratolytics and Wart Treatments

Salicylic acid softens keratin and is used for selected warts, corns and thick scale. Protect normal skin, avoid large/broken surfaces and use extra caution in children, diabetes or impaired circulation. Urea is moisturising at lower concentrations and keratolytic at higher concentrations. Do not apply strong wart preparations to face/genitals unless specifically formulated and prescribed.

Psoriasis Medicines

Vitamin D analogues: Calcipotriol regulates keratinocyte proliferation; avoid excessive quantity because of calcium disturbance risk.
Topical corticosteroids: Reduce inflammation but require potency/site limits and planned breaks or combination regimens.
Coal tar/keratolytics: Reduce scale and inflammation but may irritate, stain and be cosmetically difficult.
Systemic methotrexate: Folate antagonist/immunomodulator for severe disease; weekly—not daily—dosing is a critical safety point. Monitor full blood count, liver and renal function; prevent pregnancy and review interactions.
Ciclosporin: Rapid immunosuppression for selected severe disease; monitor blood pressure, renal function, infection and interactions.
Biologic medicines: Target specific cytokines; require specialist screening for tuberculosis/hepatitis and monitoring for infection.

Antipruritic Medicines

Emollients, cooling preparations and treating the cause are central. Oral antihistamines help histamine-mediated urticaria; sedating agents may aid short-term night-time sleep but can cause falls, impaired driving, confusion and anticholinergic effects. They do not treat every form of itch.

Sunscreens and Photoprotection

Broad-spectrum sunscreen protects against ultraviolet A and B radiation. Apply adequate quantity before exposure, reapply after sweating/washing and combine with shade, clothing and hats. Sunscreen is an adjunct, not permission for prolonged exposure. Photoprotection is important with retinoids, tetracyclines, photosensitive disease and pigment disorders.

Procedure: Applying a Topical Medicine

No.	Action	Rationale
1	Verify patient, prescription, diagnosis, medicine, concentration, vehicle, site, area, frequency, duration, allergy and expiry date.	Prevents wrong-strength/site errors and confirms that treatment fits the lesion.
2	Assess and document lesion type, distribution, size, pain, exudate, surrounding skin and systemic signs.	Provides a baseline and identifies infection or emergency disease before it is masked by treatment.
3	Explain, provide privacy, perform hand hygiene and wear gloves when exposure or transmission is possible.	Protects dignity and prevents contamination or medicine absorption by the caregiver.
4	Clean only as prescribed and pat dry. Use a clean spatula/applicator rather than dipping contaminated fingers into a jar.	Protects tissue and prevents contaminating the bulk preparation.
5	Measure the appropriate amount using FTU or prescribed quantity; apply gently in the direction of hair growth.	Achieves even dosing and reduces folliculitis from vigorous rubbing against hairs.
6	Avoid eyes, mucosa and healthy surrounding skin unless instructed; apply dressings/occlusion only when prescribed.	Prevents toxicity and unintended increased absorption.
7	Remove gloves, wash hands, store the medicine safely and document application and response.	Completes infection prevention and ensures continuity/evaluation.

Dermatological Emergencies and Severe Reactions

Anaphylaxis: Skin/mucosal changes with airway, breathing or circulation compromise require immediate intramuscular adrenaline according to emergency protocol, oxygen/support and urgent transfer.
Stevens–Johnson syndrome/toxic epidermal necrolysis: Fever, skin pain, target-like lesions, blistering, detachment and mucosal erosions after a medicine. Stop suspected non-essential culprit medicines under emergency direction, support ABC, fluids, temperature, eyes and wounds, and refer urgently.
Drug reaction with eosinophilia and systemic symptoms: Rash with fever, facial oedema, lymphadenopathy and organ injury weeks after a medicine requires urgent laboratory assessment and specialist care.
Necrotising soft-tissue infection: Pain out of proportion, rapid progression, crepitus, bullae, anaesthesia, toxicity or shock needs immediate surgical review, resuscitation and IV antibiotics.
Staphylococcal scalded-skin syndrome or extensive blistering: Requires urgent paediatric/specialist care.
Erythroderma/generalised pustular psoriasis: Widespread redness or pustules can cause heat/fluid loss, electrolyte disturbance and infection; avoid abrupt systemic steroid changes and admit/refer.
Eczema herpeticum: Rapid painful monomorphic vesicles/erosions with fever in eczema requires urgent systemic antiviral treatment.

Nursing Care Plan

Assessment

History of onset, progression, itch/pain, triggers, occupation, contacts, travel, sexual exposure where relevant, new medicines, allergies, traditional remedies and previous treatment.
Describe primary lesion, colour, border, surface, distribution, symmetry, mucosal/nail/hair involvement and signs of secondary infection.
Assess temperature, hydration, nutrition, sleep, mobility, self-image, stigma, school/work and risk of self-harm in severe visible disease.
Review microscopy/culture, full blood count, renal/liver tests, pregnancy testing and therapeutic monitoring relevant to prescribed systemic agents.

Priority Problems, Interventions and Rationales

No.	Intervention	Rationale and Desired Outcome
1	Assess itch/pain regularly; protect excoriated skin, keep nails short and use prescribed antipruritic/analgesic therapy.	Reduces scratching, sleep loss, infection and distress; patient reports tolerable symptoms.
2	Maintain skin hydration with correctly selected emollient and gentle washing; avoid known irritants.	Restores barrier function and reduces flares/fissuring.
3	Administer topical treatment using measured quantity, correct site and ordered sequence; use emollient and active drug separately as directed.	Achieves therapeutic exposure while preventing dilution, spread and toxicity.
4	Monitor spreading erythema, fever, pus, lymphangitis, severe pain and vital-sign change.	Detects secondary infection or systemic deterioration early.
5	Use contact precautions/isolation when indicated for scabies, crusted scabies or transmissible infection; manage linen safely.	Prevents institutional and household transmission.
6	Monitor systemic therapy using medicine-specific observations and laboratory tests; check pregnancy risk where teratogenic medicines are used.	Detects marrow, liver, renal, blood-pressure, infection or fetal risk before serious harm.
7	Teach with demonstration and teach-back; provide a written schedule for multiple products.	Improves adherence and distinguishes maintenance emollient from short-course active medicine.
8	Support privacy, body image and coping; address stigma and refer severe psychological distress.	Visible disease affects relationships, school/work and mental health as well as skin.

Patient Education and Prevention

Use only labelled medicines for the diagnosed condition; avoid sharing or unlabelled “mixed creams.”
Apply the demonstrated quantity and complete the planned course; more is not necessarily better.
Do not scratch, squeeze acne lesions or cut warts/corns with blades.
Keep infected areas, personal towels, clothing and razors separate when transmission is possible.
Use sun protection with photosensitising medicines.
Return for fever, rapid spread, blistering, mucosal lesions, facial swelling, breathing difficulty or severe pain.

Uganda-Relevant Practice

Follow current Uganda Clinical Guidelines and the Essential Medicines and Health Supplies List; availability and approved strengths vary.
Consider HIV-associated dermatoses, scabies, tinea capitis, bacterial infection, medicine reactions, leprosy and other skin-related neglected tropical diseases where clinically relevant.
Counsel respectfully about harmful bleaching products, potent steroid mixtures and non-sterile traditional applications without dismissing the patient’s beliefs.
Refer early when microscopy, culture, biopsy, dermatology review, burn care or monitoring for systemic therapy is unavailable.

Before topical treatment remember “S-K-I-N”:
S — Site, surface area and severity.
K — Know the diagnosis, strength and vehicle.
I — Infection, interactions and integrity of the barrier.
N — Nursing monitoring, quantity and next review.

Revision Summary

Correct diagnosis, potency, vehicle, quantity and duration determine safety.
Emollients are active barrier treatment and should be used generously.
Topical steroids reduce inflammation but can cause atrophy, infection masking and systemic effects.
Antibiotics should not be used routinely or alone for acne.
Scabies care fails when the whole skin surface, repeat dose, contacts or linen are ignored.
Isotretinoin, methotrexate, ciclosporin and biologics require specialist safeguards and monitoring.
Blistering, mucosal disease, severe skin pain, rapid spread or systemic illness requires urgent escalation.

Authoritative References

This educational article does not replace patient-specific diagnosis, an authorised prescription, local protocol or specialist care.